Understanding Your Minnesota Health Care Program Payer ID for Efficient Billing

Navigating the complexities of healthcare billing can be challenging, especially when dealing with different payer systems. For healthcare providers in Minnesota, understanding the nuances of billing Minnesota Health Care Programs (MHCP) is crucial for ensuring timely and accurate reimbursements. A key component of this process is correctly identifying the payer, often referred to as the Minnesota Health Care Program payer ID, to facilitate smooth claims processing and avoid unnecessary delays. This guide provides a comprehensive overview of MHCP billing policies, requirements, and how to effectively manage your claims within the system, focusing on the essential elements for successful submissions.

Minnesota Health Care Programs, which includes Medical Assistance (Medicaid) and MinnesotaCare, operates on a fee-for-service (FFS) delivery system. This means that providers are reimbursed for each covered service they provide to eligible members. To participate and receive payments, providers and their billing organizations must strictly adhere to the MHCP billing policies outlined in the MHCP Provider Manual. These policies cover a wide range of topics, from general billing requirements to specific procedures for electronic claims submission and handling claim adjustments.

For members enrolled in a Managed Care Organization (MCO) contracted with MHCP, healthcare services are managed through their MCO. It’s important for providers to recognize this distinction as billing procedures may differ. Resources for MCO contact information and specific billing guidelines for MCO-enrolled members are readily available on the MCO contacts for MHCP providers webpage.

The landscape of healthcare billing is also shaped by federal regulations, primarily the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA mandates the use of universal standards for electronic billing and administrative transactions across all healthcare providers and payers. Furthermore, Minnesota’s Uniform Electronic Transactions and Implementation Guide Standards stipulate that all healthcare claims originating in Minnesota must be submitted electronically, streamlining the process and enhancing efficiency.

This guide will delve into the essential billing policies for all MHCP providers, covering aspects such as service coordination, managing overlapping coverage, free-care policies, general and timely billing requirements, coding schemes, electronic billing via MN–ITS, billing as a consolidated provider, billing organization responsibilities, eligibility verification, electronic claims processes, claim reconsiderations, replacement and void claim procedures, utilizing the MN–ITS mailbox, understanding remittance advice, tax implications, MHCP reimbursement as full payment, prompt payment guidelines, and additional resources. By understanding these policies and procedures, providers can effectively navigate the MHCP billing system and ensure accurate and timely payment for the services they render.

Key Billing Policy Areas for Minnesota Health Care Providers

To ensure smooth and compliant billing practices within the Minnesota Health Care Programs, providers must familiarize themselves with several key policy areas. These areas range from coordinating patient care to understanding the technical aspects of electronic claim submissions.

Coordination of Services: Ensuring Comprehensive Patient Care

A fundamental aspect of responsible healthcare provision is the coordination of services. MHCP expects providers to actively engage with members to determine if they are receiving similar services from other providers. If overlapping services are identified, providers are responsible for coordinating care and documenting these efforts in the member’s record. It’s important to note that MHCP does not proactively inform providers about services a member might be receiving elsewhere; this responsibility rests with the individual providers to ensure comprehensive and non-duplicative care.

Navigating Overlapping MHCP and Managed Care Organization (MCO) Coverage

Situations can arise where a member has overlapping coverage between Medical Assistance and MinnesotaCare for a limited period. To correctly bill in these instances, it’s crucial to understand the primary and secondary payer roles. In cases of overlapping coverage, the MCO is considered the primary payer, and MHCP fee-for-service acts as the secondary payer for cost-sharing purposes.

When billing claims to MHCP under overlapping coverage scenarios, specific documentation is required:

• Electronic Claim Attachment: Submit an electronic claim attachment as per MHCP guidelines.
• Cover Sheet: Include a cover sheet indicating the member’s overlapping coverage dates.
• MCO Explanation of Benefits (EOB): Attach the MCO’s Explanation of Benefits statement.
• Coordination of Benefits (COB) Information: Complete the Coordination of Benefits section on the claim form.

For pharmacy claims with overlapping coverage, the process involves:

1. Entering COB information on the claim.
2. Submitting the claim, which will initially be denied with NCPDP reject code AF.
3. Contacting the MHCP Provider Resource Center to create a case for claim reprocessing.
4. The pharmacy will be informed of payment details after the Claims unit reprocesses the claim.

Free-Care Policy: Billing for Services Regardless of Standard Practice

MHCP’s free-care policy clarifies that providers can bill for covered services even if they offer the same services for free to other patients. The key factor for reimbursement eligibility is that the services must meet all other MHCP coverage criteria. This policy ensures that providers are not penalized for offering free services to some patient populations while still being able to bill MHCP for eligible members.

General Billing Requirements: Foundational Principles for Claim Submissions

Adherence to general billing requirements is paramount for all MHCP providers. These requirements establish the foundational principles for accurate and compliant claim submissions:

• Service Provision Prerequisite: Claims should only be submitted after providing one or more MHCP-covered services.
• Date of Service Accuracy: Bill only for dates on which services were actually rendered, with exceptions only for specific services like Elderly Waiver (EW) or Alternative Care (AC) environmental accessibility adaptations, where payments are prorated as per service authorization.
• Usual and Customary Charges: Bill the provider’s standard charge for the service.
• Monthly Billing Limit: Each claim should encompass services provided within a single calendar month.
• Electronic Claim Submission Mandate: All claims must be submitted electronically, aligning with state and federal regulations.

Timely Billing: Adhering to Submission Deadlines

Submitting claims within the stipulated timeframes is critical to avoid claim denials. MHCP has specific timely billing requirements:

• Standard Claims: Submit claims, including Medicare crossover and third-party liability claims, within 12 months from the date of service.
• Replacement Claims: Submit replacement claims within six months of the date of incorrect payment or 12 months from the date of service, whichever is later.
• Medicare Crossover Claims (Non-Automatic): Submit non-automatically crossed over Medicare claims within six months of the Medicare determination date or 12 months from the date of service, whichever is later.
• Erroneously Denied Claims: Resubmit claims denied due to system errors or incorrect county information within 12 months of the service date or six months from the date of county correction, whichever is later.
• Claims Exceeding One Year: Claims older than one year require appropriate, dated documentation and are subject to review with no guarantee of payment.

Coding Schemes: Utilizing Standardized Medical Codes

Using correct and current coding schemes is essential for accurate claim processing. MHCP mandates the use of HIPAA-compliant codes and the most up-to-date guidelines. Providers should utilize the manuals relevant to their service types, including:

• CDT (Current Dental Terminology)
• CPT (HCPCS Level I: Physicians’ Current Procedural Terminology)
• HCPCS (Healthcare Common Procedural Coding System)
• ICD-10-CM (International Classification of Diseases 10th Revision Clinical Modification)
• NDC (National Drug Codes)
• UB-04 Data Specifications Manual

Modifiers, particularly HCPCS modifiers, are crucial for specifying service alterations, supply details, or transportation origins. Minnesota also uses specific U modifiers, which are detailed in the MHCP Provider Manual. Unlisted procedure codes should only be used when no specific code is available, requiring detailed descriptions and documentation.

MN–ITS and Electronic Billing: Leveraging the State’s Transaction System

MN–ITS (MN–ITS) is MHCP’s free, secure, web-based system for electronic transactions, including claim submissions and eligibility inquiries. Providers can use MN–ITS for:

• Individual claim submissions via MN–ITS Interactive.
• Batch submissions for billing organizations or those using HIPAA-compliant software via MN–ITS Batch.

Registration for MN–ITS is mandatory for providers to perform functions such as verifying enrollment status, checking eligibility, submitting authorizations and service agreements, retrieving letters, submitting claims, copying or replacing claims, checking claim status, submitting performance-based payments, and accessing Remittance Advices (RAs). Registration involves agreeing to the EDI Trading Partner Addendum, which updates the MHCP Provider Agreement for electronic transactions. Providers using billing organizations must also register and are responsible for all claims submitted under their provider ID.

Billing as a Consolidated Provider: Managing Multiple Locations or Service Types

Providers enrolled with MHCP who have multiple locations or service types are considered consolidated providers under a provider type 33 record. Consolidated providers must take extra steps during billing to specify the location or service provided. Guidance for billing as a consolidated provider is available in MN–ITS user guides for different claim types (837P, 837I, and 837D).

Billing Organization Responsibilities: Understanding Limitations and Compliance

MHCP prohibits providers from submitting claims through factors, which are entities that advance money on accounts receivable. Billing organizations must operate within MHCP guidelines, ensuring they do not function as prohibited factors. Detailed responsibilities for billing organizations are available in the MHCP Provider Manual.

Eligibility Requests and Responses: Verifying Coverage Before Service

MHCP mandates eligibility verification prior to service delivery. Providers must use MN–ITS for eligibility inquiries (270) and responses, as clearinghouses are not HIPAA compliant for these transactions. Eligibility responses provide critical information, including:

• Major program and MCO enrollment status.
• Other insurance, TPL, or Medicare coverage.
• Special indicators (transportation, hospice, living arrangement).
• Copay and spenddown details.
• Waiver program and restricted member indicators.
• Benefit limits and elderly waiver obligations.
• Eyeglass payment eligibility.

For eligibility verification beyond one year, providers should contact the MHCP Provider Resource Center.

Electronic Claims: Specific Guidelines for Different Provider Types

Electronic claim submissions must adhere to specific guidelines that can vary based on provider type. Providers are advised to consult the MHCP provider types webpage and their specific provider type information for detailed claim submission instructions.

Reconsideration of a Claim (Appeals vs. New or Replacement): Addressing Claim Denials

MHCP FFS does not use the AUC appeals form. For claim reconsideration, providers should:

1. Review Claim Adjustment Reason Codes to understand denial reasons.
2. Determine if the claim can be corrected and resubmitted or if it requires an electronic claim attachment with supporting documentation.
3. For paid claims needing adjustment, submit a replacement claim. For denied claims, submit a new or copy claim. Claims submitted via MN–ITS DDE can be copied or replaced using the Request Claim Status feature.

Replacement Claims: Correcting Paid Claims

Replacement claims are used to correct incorrectly paid claims due to billing errors or third-party payments. They are necessary when:

• A claim is paid incorrectly due to a billing error.
• Third-party payment is received after MHCP payment.

Replacement claims must be submitted within specific timeframes, generally 12 months from service date or six months from payment date. Overpaid claims can be replaced or voided electronically. Specific processes depend on whether the claim is within timely filing limits and the reason for replacement (overpayment vs. underpayment).

Void Claims: Returning Full Claim Payments

To return an entire claim payment to MHCP, providers must void the claim in MN–ITS. Voided amounts are deducted from subsequent remittance advices. Claims voided after timely billing deadlines cannot be resubmitted. Specific procedures apply to void claims paid under old MHCP IDs, claims paid over three years ago, claims paid to inactive providers, or claims identified as “claim type: gross adj” on remittance advice. Voiding in these situations often requires contacting the MHCP Provider Resource Center.

MN–ITS Mailbox: Secure Communication and Document Retrieval

The MN–ITS mailbox is used for secure communication and document retrieval, including Remittance Advices. Providers can search and retrieve content within a rolling 30-day period. Providers must regularly manage their MN–ITS mailbox and adhere to state and federal record retention requirements.

Remittance Advice (RA): Understanding Payment Details

Remittance Advice (RA) provides detailed payment information for processed claims. MHCP uses the HIPAA-standard electronic RA (835_X12) transaction. RAs detail payments, adjustments, and reasons for any discrepancies between billed charges and payments. RAs are typically ordered alphabetically by member name but can be re-sequenced by request. Providers receive RAs as PDF files or X12 835 batch files in their MN–ITS mailbox. Software is needed to translate X12 835 files. Providers can manage their RA format and billing organization affiliations using the Electronic Remittance Advice Request form.

Taxes and 1099 Forms: Understanding Tax Obligations

MHCP does not withhold taxes from provider payments. IRS 1099 forms are issued annually for payments made. DHS issues 1099s for paper check payments, while Minnesota Management and Budget (MMB) issues them for electronic funds transfers (EFT).

MHCP Reimbursement is Payment in Full: Adhering to Payment Acceptance Rules

Providers must accept MHCP reimbursement as full payment for covered services. Balance billing members or seeking additional payments from other sources is prohibited, except for allowed cost-sharing like spenddowns, copays, family deductibles, or insurance payments made directly to the member.

Prompt Payment: Expecting Timely Claim Processing

MHCP is mandated to pay or deny clean claims within 30 days and complex claims within 90 days of receipt. Clean claims are primary MHCP claims without attachments. Complex claims include replacement claims, Medicare crossovers, third-party liability claims, claims with notes or attachments.

Additional Resources: Expanding Your Knowledge Base

For further information on billing policies and related topics, providers can refer to additional resources on:

• Authorization
• Fraud Prevention

Legal References: Statutory and Regulatory Basis

MHCP billing policies are grounded in various legal statutes and regulations, including:

• Minnesota Statutes, 62Q.75 (Prompt Payment Required)
• Minnesota Statues, 256S.18 (Elderly waiver cost limits)
• Minnesota Statues, 256b.0913, subdivision 4 (7) (Alternative Care Program–Eligibility for funding for services for nonmedical assistance recipients)
• Code of Federal Regulations, title 42, section 447.10 (Prohibition against reassignment of provider claims)
• Code of Federal Regulations, title 42, section 447.15 (Acceptance of state payment as payment in full)
• Code of Federal Regulations, title 42, section 447.45 (Timely claims payment)

By understanding and adhering to these comprehensive billing policies, Minnesota healthcare providers can ensure efficient operations, minimize claim rejections, and maintain compliance within the Minnesota Health Care Programs framework.